INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 20, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Naaman Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of six applicable records reviewed.
Client #1 was admitted on November 30, 2022 and was still active at the time of the inspection. A treatment plan update was completed on April 11, 2023 and an update was due no later than June 11, 2023; however, none was completed.
Client #3 was admitted on October 18, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on November 15, 2022 and an update was due no later than January 15, 2023; however, it was not completed until February 16, 2023.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the September 6, 2022 licensing inspection.
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Plan of Correction
The clinical director reviewed audit finding with clinical supervisor and lead counselors on 7-27-23. The Clinical Supervisor and Lead Counselor will review charts to verify compliance and will follow up and train accordingly. All treatment plans will be updated within the 60 day timeframe according to Naaman Center policy. Compliance will be met by 8/17/23. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of six applicable records reviewed.
Client #1 was admitted on November 30, 2022 and was still active at the time of the inspection. The treatment plan dated December 20, 2022 indicated individual sessions weekly. There was no documentation that the client received individual therapy between June 6-20 and June 21- July 20, 2023.
Client #5 was admitted on August 31, 2022 and was discharged on March 6, 2023. The treatment plan dated December 5, 2022 indicated individual sessions weekly. There was no documentation of the client receiving individual therapy between December 5-19, December 20-January 9, January 10-February 6, and February 7-20, 2023.
Client #6 was admitted on June 13, 2022 and was discharged on February 21, 2023. The treatment plan dated December 12, 2022 indicated weekly individual sessions. There was no documentation that the client received individual sessions in the month of January.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical director reviewed audit finding with clinical supervisor and lead counselors on 7-27-23. The Clinical Supervisor and Lead Counselor will review charts to verify compliance and will follow up and train accordingly. All treatment plans will accurately state the frequency of services being received. If Service frequency is changed, it will be updated in treatment plan instead of else ware in the chart. Compliance will be met by 8/17/23. |